Farmer Emanuel has 10,000 head of cattle in his beef herd. He prides himself in staying up to date on all the latest methods, so he knows that adding a certain antibiotic to their feed will reduce the incidence of intestinal infections, and will increase his annual overall yield, measured in pounds of beef, by 7%. Unfortunately, he also knows that roughly one in 200 of his cattle will experience a likely fatal allergic reaction to the antibiotic. It is possible to do a blood test to determine which specific members of the herd are allergic, but the test itself is quite expensive, and the logistics of separating the allergic cattle at feeding time and providing them with their own antibiotic-free feed would be expensive enough to entirely wipe out his savings.

Obviously, the cost-effective solution is for Farmer Emanuel to give antibiotic-treated feed to all his cattle, accepting the losses of a few head as the necessary price for an impressive overall gain in productivity. He would be an ineffective and incompetent rancher indeed if he were to pass up this opportunity to achieve cost-effectiveness.

For the last two posts (here and here) DrRich has had some fun in deconstructing the Sixth edition of the American College of Physicians’ Ethics Manual, and especially in demonstrating how the ACP leadership has managed to wrap its collective tongue around the axle defending its unfortunate choice of the word “parsimonious” to describe the ideal mind-set of the modern physician. In the present post, DrRich will discuss a somewhat more serious aspect of the document, namely, what this re-statement of medical ethics really means, and why it was produced.

The Sixth Edition of the ACP Ethics Manual elevates the term “cost-effectiveness” to an ethical mandate; and furthermore, it locks this often ambiguous term down into its apparently final form, and in so doing formally launches the era of herd medicine.

Until now, efforts at covert healthcare rationing have been aimed mainly at coercing individual physicians to surreptitiously withhold certain medical services at the bedside. Mainly, doctors were to accomplish this withholding of care simply by failing to inform patients of all their medical options, or perhaps more commonly, by painting certain medical options in an unfavorable light (so that, while they were, in fact, offered, they were offered in such a way that the patient would almost certainly turn them down).

What the Central Authority has learned, over the past 15 years, is that this style of covert rationing simply doesn’t work. It still leaves medical decisions up to individual doctors and individual patients, who have apparently continued to act against the best interests of the collective despite all the coercion that has been brought to bear. The end result has been unremittingly bad – healthcare costs have continued to rise at multiples of both the GDP and the general level of inflation. It has become obvious to the Central Authority that, in order to set the matter right, all healthcare decisions will have to be made centrally, from the top down.

Accordingly, during the first decade of the New Millennium we saw a steadily rising emphasis on “guidelines.” Guidelines are not intrinsically a bad thing, and indeed, when properly used can be greatly beneficial to both doctors and patients. But in a relatively gradual process, guidelines came to be spoken of as more than merely guidelines – that is, as more than helpful considerations which doctors ought to take into serious account when deciding what’s best for an individual patient. Instead, guidelines have become directives for definite action.

In 2010, the Obamacare legislation took the concept of “guidelines” a giant step forward, and essentially rendered it a crime for doctors to “violate” guidelines, which are now to be handed down by federally-appointed panels of experts. As if to emphasize this new paradigm, the Department of Justice a year ago began a secretive investigation of an unknown number of electrophysiologists, for alleged violations of guidelines for using implantable defibrillators. We do not know if any criminal charges will be brought (and because the particular aspect of those guidelines which doctors have allegedly violated were based on rather flimsy evidence, perhaps not), but during the past year American electrophysiologists have certainly been intimidated into reducing the number of implantable defibrillators they offer to their patients. (And so, whether any charges come out of this “investigation” or not, mission accomplished!)

Dear Reader, how do you suppose some of these electrophysiologists must feel, after failing to offer implantable defibrillators to their patients who they believe have clear-cut indications for the device, knowing that by failing to offer this treatment their patients may very well (and very predictably) suffer sudden death? At least a few doctors, DrRich warrants, are probably feeling very guilty about it.

And here is the real import of the updated Ethics Manual. It aims to assuage the guilty conscience of physicians who follow handed-down guidelines to the letter, even against their better medical judgment, instead of tailoring the application of those guidelines to the benefit of their individual patients (which, DrRich feels compelled to remind his readers, was the original but now archaic intention of “guidelines.”) Doctors who had been feeling badly because they were preserving their own skin at the cost of their patients’ can now take heart. They are not behaving selfishly at all, the New Ethics assures them. They are in fact acting for the greater good of the collective – and therefore they are obeying a higher principle of ethics than those outmoded principles mentioned in the Hippocratic Oath.

While herd medicine was made the law of the land by Obamacare, until now it was still technically unethical. The ACP’s new Ethics Manual repairs that uncomfortable discrepancy, using, of course, what has become the traditional methodology. (That is, when it becomes difficult or impossible to adhere to ethical precepts, change them.)

For those who missed it, the relevant passage of the new Ethics Manual states that physicians have an ethical obligation to “practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to diagnose a condition and treat a patient respects the need to use resources wisely. . .”

Dr. Ezekiel Emanuel offers the midrash on this passage, in his editorial which accompanied the publication of the new Ethics Manual. Emanuel rhapsodizes that it is “truly remarkable” that an “authoritative medical body [is] using such words as ‘efficient’ and ‘parsimonious’ – and without ‘qualifications’ – to describe the ideal physician’s practices.” Dr. Emanuel notes further that to fulfill this new ethical obligation toward efficiency and parsimony, the Ethics Manual specifies that doctors should act based on “the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.”

And that, readers, is the key, for it specifies how doctors, in pursuit of the new ethics, are to act. They are to follow the “best evidence,” in particular, the best evidence on “cost-effectiveness.”

In the past, when doctors were exhorted to practice cost-effectively, the term was used as a general admonition to not be wasteful. But here, in this formal ethics document (as in the Obamacare legislation), it has now become a term of art. “Cost-effective” now has a specific meaning. It is cost-effectiveness as determined by “best evidence,” and since any body of clinical evidence will inevitably have conflicts, and since doctors cannot be expected (or permitted) to determine for themselves which evidence is best in every clinical situation, Dr. Emanuel is talking about the “best evidence” which will be determined by one of his panels of experts.

Therefore, the ACP’s new Ethics Manual stipulates that it is now an ethical obligation for doctors to follow expert-produced guidelines to the letter.

But in the real world, there is no single “best” determination of cost-effectiveness. This is because any determination of cost-effectiveness depends entirely on who is making the assessment. For instance, when DrRich was deciding whether to buy a smoke alarm to protect himself and his family from dying in a fiery inferno, he judged it to be cost-effective to do so. For a mere $20, DrRich was able to protect himself and his family from death or injury, in the unlikely event that a fire should occur in his home. A bargain to be sure, and at least by DrRich’s lights it was highly cost-effective (if only for the peace of mind it brought him).

But if the purchase of fire alarms was covered under Obamacare (and why should it not be, since fire-related injury is certainly a medical problem, which produces a burden for our healthcare system), then the cost effectiveness calculation would look very different. For while fire alarms indeed save lives, they do so at an exorbitant cost – likely more than a million dollars per life-year saved. Clearly, from the perspective of the collective, the purchase of fire alarms ought to be made illegal, and owning one a crime.

And the only reason it’s not a crime is that such Fire Protection Appliances have not (yet) been designated as being subject to the rulings of the US Preventive Services Task Force.

It is axiomatic, therefore, that the assessment of the cost-effectiveness of any product or service will depend on which party of interest is doing the assessment. And often, what might very well be considered cost-effective by an individual might just as well be considered criminally cost-ineffective by the collective.

And so we have the situation, under both Obamacare and now under the new code of medical ethics, in which doctors are obligated to practice medicine cost-effectively, and the kind of cost-effectiveness being referred to is decidedly NOT the kind that applies to individuals. It’s the kind that applies to the collective.

Those assembling the GOD panels (Government Operatives Deliberating) – the panels which will determine the most cost-effective way to practice medicine, and which will distribute rules down to American physicians for deciding who gets what, when and how – tell us that what’s good for the herd is certainly what’s good for the individual. Indeed, this is the precise message of Dr. Hood, president of the ACP.

For the majority of Farmer Emanuel’s beef cattle, this may very well be the case. But for the unfortunate beeves who will turn out to have a fatal allergy to the antibiotic, and who could have been saved with a little extra effort aimed at optimizing the results for every individual, well, not so much. (Progressives like Keynes have been known to justify such results by noting that whatever we do has limited significance for individuals, since, in the end we individuals – like the beef cattle – are all dead anyway.)

Until last week American physicians were ethically obligated to optimize their medical care for every individual, as difficult and dangerous as it has become for doctors to do so in recent years. No doubt some of them will be relieved to know that their ethical obligations now have been formally changed, to comport with the requirements of their masters, and the facts on the ground.

17 Responses to “Herd Medicine”

I am normally not one to nitpick, but in this case someone clearly needs to point out to Dr. Rich that it is physically impossible to simultaneously “open wide” and say “moo”. Or “baa” for that matter. From this one can only infer that the folks promulgating these policies would be much happier if Dr. Rich and the rest of us in the healthcare herd would simply do as we are asked and keep our mouths shut.

I can’t help but be reminded of one relatively recent Western medical tradition that went down this road already, with the inevitable outcome that a great number of atrocities were rationalized for the “greater good.” Indeed, I recently attended a grand rounds where I was informed that we should no longer refer to “granulomatosis with polyangiitis” by the eponymous “Wegener’s granulomatosis” because of the unfortunate association which Dr. Wegener had with that medical tradition. So, while we are busy scrubbing the literature of the memory of these physicians, we are simultaneously putting into place the very ethical constructs which — taken to their logical extremes — allowed them to practice in such a way in the first place.

I wonder if the word will filter into the medical community, that there are some patients who should get the benefit of some extra effort, considering their long careers of service to the community. And, considering their well-funded superior health insurance.

I am thinking of the politicians, federal workers, and union members who have contributed a lifetime of selfless service to maintaining our society, and who are explicitly exempt from many of the restrictions and policies of ObamaCare.

The farmers do not apply the same criteria to themselves as to the herds. That would be laughable.

I have written, somewhere in these pages, an explanation of why it is a very good thing for the collective to elevate and coddle the Dear Leaders, the ones who, under Progressivism, determine who gets what, when and how. For instance, to your point, the overriding need to provide the leader class with the very best healthcare possible will end up as the one and only incentive to maintain at least some semblance of medical progress.

It is interesting that spokespeople for the ACP(one at least)talk about the New Ethics as really nothing new,no big deal. Dr Virgina Hood,ACP President when interviewed by Modern Medicine said in regard to their treatment of the issue of efficient care that “it’s been given slightly greater emphasis” I recall she took a similar position in the “debate” that you and she had a while back regarding the New Professionalism .On the other hand, Dr. Ezekiel Emanuel, writing in the Annals of Internal Medicine said that their stand on efficient and parsimonious care as characteristics of the ideal physician’s practices was “truly remarkable”. “Slightly greater emphasis” or “truly remarkable”-you have to wonder if they are talking about the same document.

Good observation. They are indeed talking about the same document. Dr. Hood’s job is to mollify the membership of her organization, and she is adept at saying there’s really nothing new here (so just move along, move along). On the other hand Dr. Emanuel’s job, presumably, is to establish the government panels which will determine who gets what, when and how – so he’s not bashful about celebrating what the new ethics policy actually means.

The document was written artfully enough to allow Dr. Hood a certain amount of plausible deniability, while at the same time allowing Dr. Emanuel all the ammunition he needs. All in all, it was a very successful effort, since apparently only a few old cranks (like us) realize what is actually going on.

As a physician from the UK, reading your blog is a revelation. It seems to me that you guys are moving towards our position at a frighteningly breakneck speed. Although I feel your pain, having 1 system is better than having a thousand , is less expensive and does saves lives. For 1 patient lost at the altar of communitarianism 3 will be saved. Carry on the good work- reading your contributions is an indulgence I look forward to.

I’m from a family where many of us “cows” have the “deadly allergy to the antibiotics given the entire herd.” Most of my immediate family has been decimated by the “no-history, put em’ all on the same drugs” approach to medicine. Most of the women in my extended family, educated, high achievers, are told not to take thyroid medicine, that there are no good answers. So my mother, always a sensitive person, changed after being put on a low dose of thyroid medicine, and now has “Alzheimers.” (And it doesn’t look like Alzheimer’s at all, and I’m fighting that diagnosis, although I don’t know how far I will get as an average citizen without medical sophistication.) Both of my brothers are dead in medical circumstances where the rules did not meet their needs. I must take thyroid medicine, and doctors kept putting me on steroids which were a disaster for me, and by some sort of luck, I’m surviving for now, although not without compromise. I’m disgusted with a medical system that does not help individuals who are “different” but instead knowingly murders them. It does not save money when you disable and harm individuals by practicing herd medicine. It just shifts expenses into other categories, like expensive long term care for my mother, which my father pays. As for all of the science that is supposedly proves how we should be treated, I quote T.S. Eliot: “Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?”

Since the government now asserts that they can legitimately control individual behavior in the form of compelling citizens to purchase health insurance, and they have also demonstrated an unrestrained commitment to controlling costs, it stands to reason that The Central Authority will soon limit (or in this case, compel) individual behavior to reduce health care costs.

As much as I enjoy my good health, in this new era I don’t think it’s really reasonable for me to expect everyone else to pitch in for my health expenses in my later years. It’s probably better for everyone (the herd) if I were to start smoking now in my early 40s, thus cutting short all those expensive treatments I would surely require in the years to come. I don’t expect to be particularly productive after age 65 or so anyway, spending most of my time reading and caring for grandchildren etc.

No doubt, as a cardiologist, you will be expected to lead the charge to reduce the costs of treating cardiovascular diseases- with the most efficient method being that of smoking advocacy. Once you’ve decided on which brand of cigarette you plan to recommend to your patients (which you will be required to do), please let me know. I’m sorry to ask for the free medical advice, but I’m just too healthy to need a cardiologist otherwise.

First, I admit to bias as a member of the ACP Board of Regents.
DrRich (whom I like and admire) has used a technique that we all use. He has established a straw man and beat that straw man into submission.
ACP advocates strongly for high-value, cost-conscious care (HVCCC). In fact a recent Annals article – Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care – http://www.annals.org/content/156/2/147.abstract – very explicitly attacks low value high cost care.
Advocating for HVCCC does not mean advocating for rationing based on cost alone.
As DrRich always states, we have covert rationing and we believe that rationing has no relation to value.
ACP has challenged all physicians to avoid medications and tests that do not have high value. How is that “herd medicine”?
Please review the recommendations in the recent Annals article and tell us where we have developed recommendations for cost reasons only.
I admire your debating skills, but in my opinion you are not addressing the same question that we are addressing.
I speak from clinical experience. I see too many tests ordered that cannot help the patient. I see too many treatments that cost too much without a clear advantage over less expensive treatments.
We should strive for high value care for all our patients. We should eschew low value expensive care for most patients (of course one can construct exceptions to this generalization). Let’s not let hyperbole confuse the issue. We cannot afford unnecessary expenses. We challenge you to define unnecessary. I think you can.

I posted a reply to “chestcracker” which was quite serious. If you feel that it does not fit in with the humorous tone of your blog, feel free to delete it. I was overeager to chime in, finally having found someone who seemed to echo my point of view about the way medicine is practiced and how it can hurt some people. Consider that this approach to medicine is very likely to affect families disproportionately, to the extent that individuals within a family may share some of the same sensitivities or predispostions.